Aboriginal primary health care: red tape nightmare

The National Health and Hospitals Reform Commission (NHHRC) has recommended radical change in the way health care for Aboriginal and Torres Strait Islander people is funded.

The proposed National Aboriginal and Torres Strait Islander Health Authority (NATSIHA) would act as a third-party payer for all health care used by Indigenous Australians who choose to enrol; it would support the critical role of Aboriginal Community Controlled Health Services; and it could engage in long-term planning and solve several existing problems.

This all sounds good. However, the challenge is to turn good intentions into effective action.

I am one of a team that has researched the current funding situation, and the NHHRC proposals could solve most of the problems we identified.

For example, one Service in remote Australia received 42 separate funding grants in one financial year, each with its own accounting and reporting requirements.

There are two problems with this.

The first is that PHC is a complex thing to deliver - it must be responsive to people's needs. It can't work by just stringing together a collection of targeted funding programs for specific conditions.

The targeted funding can help, but only if there is an adequate base of untied core PHC funding. Most ACCHSs have some of this core funding, but not enough of it, and the balance is not right.

The second problem is the waste of health care resources in all the red tape that comes with so many bits and pieces of funding. These problems are recognised by the public servants who administer the programs, but none of them has the power to fix it.

Both Commonwealth and state/territory governments provide funding through several different areas in their health departments, and some comes from other portfolios like family and community care and justice.

Each of these bodies is only concerned with their programs, not with the resulting spaghetti bowl of separate grants that the ACCHSs have to manage. The Office for Aboriginal and Torres Strait Islander Health (OATSIH) in Canberra is the biggest funder, and they have been making positive moves (longer time frames, more core funding, and fewer separate grants). But even if OATSIH gets it right, it won't solve the problem.

The involvement of both levels of government means that no-one takes overall responsibility.

In spite of all this, the ACCHS sector is effective, and has done a better job than governments in many parts of the country in providing quality health services to Indigenous people. And the sector is making progress - on mother's and babies' health, and on better control of chronic diseases, for example. The Commission is right to call for strong support for this sector.

International evidence indicates that funding for ACCHSs should be based on a more modern approach to contracting, which acknowledges the kind of funding relationship needed to ensure good health care in the long-term, with shared risk and accountability.

An alliance approach to contracts would involve longer time-frames (instead of one- to three-year grants); a base of core PHC funding; simplified reporting requirements; lower transaction costs (i.e. costs of managing the contracts); and a sharing of risk and mutual accountability.

The proposed NATSIHA could adopt this approach, and solve many problems.

If all funding for Aboriginal health was put into one bucket, and managed by an agency that was focused only on funding Indigenous health care, things could be simpler.

If it included in its decision-making the right representation, structures and processes to ensure respect for the needs and preferences of Indigenous people and communities, it could make good decisions.

It could fund primary health care properly, reduce complexity, build long-term relationships, share risks, and build meaningful two-way accountability. And it could bring funding for the ACCHS sector up to the needed levels.

But these are big 'ifs', and the plan needs more work.

Now is the time for some serious testing, listening, and a willingness to act on the evidence. What is needed is a real effort to ensure agreements about change are implemented, with serious intent through respectful processes.

The ACCHS sector is organised, skilful and ready to engage. Now government needs to get its contribution right.

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